Table of Contents
What is peptic ulcer disease?
The term peptic ulcer applies to ulceration of mucosa near the acid bearing region of the gastrointestinal tract.
The most common affected regions are
Stomach: here it is known as gastric ulcer
Duodenum: Here it is known as the duodenal ulcer
The lower part of the esophagus: Ulcer here is mostly due to acid reflux
Jejunum: Here ulcer develops at the site of gastrointestinal anastomosis and
It is rarely seen in relation to ectopic gastric mucosa (near a Mackel’s diverticulum)
Gastric ulcer and duodenal ulcer is the most common form of peptic ulcer and a common health problem of many people.
Causes
Causes of gastric ulcer:
- Most common cause is H pylori infection
- Excessive and recurrent use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin (Bayer), Ibuprofen (Advil), and many others
- Neoplasm like carcinoma, lymphoma, lymphosarcoma
- Stress
- Diseases like Crohn’s disease
- Some Viral infections such as herpes simplex, cytomegalovirus
Causes of duodenal ulcer:
- The common cause is H pylori infection and NSAIDs as mentioned above
- Uncommon causes include
Zollinger Ellison syndrome is also known as ZE syndrome or gastrinoma
Hypercalcemia
Granulomatous diseases like Crohn’s disease, sarcoidosis
Neoplasm like leiomyoma, lymphoma, carcinoma
Infections like tuberculosis, herpes simplex, cytomegalovirus
Ectopic pancreatic tissue
Aggressive factors causing peptic ulcers include:
- Increased acid secretion is present in genetic family history, large parietal cell mass, and persons with blood group O
- Excessive use of smoking and alcohol
- Stress and dietetics errors like excessive use of spices and food irritants
Defensive factors causing peptic ulcer include:
- Prostaglandin secretion
- Bicarbonate secretion by stomach
- Rapid mucosal cell turnover
- Sieve-like structure of mucus physically prevents the entry of large pepsin molecules
- Secretion of HCO3 ions by epithelial cells which diffuses into the mucus and neutralizes any H ions which cause autodigestion of mucosal cell
Symptoms
Pain:
- Nature: The most common symptom is abdominal pain. Usually burning or gnawing in nature. It can be moderate, very mild, or severe.
- Location: Pain is mostly located at the epigastric region to an area about 1 inch in diameter between the xiphoid process and umbilicus. But it can also occur anywhere in the abdomen, retrosternal region, or in the back also in case of a posterior ulcer.
- Relation with food: Pain is invariable absent in the morning. It is usually present two to three hours after a meal and is eased by food. There may also be characteristic nocturnal distress between 12 and 2 a.m.
- Aggravation: Pain is aggravated by coarse food, tobacco, alcohol, nervous tension, under fatigue, etc. It is relieved after vomiting of acid fluid.
Other symptoms: may be present even if the pain is not there like…
- Anorexia and indigestion,
- Heartburn,
- Weight loss without any other major cause,
- Nausea and vomiting
Investigation and Diagnosis of peptic ulcer
Endoscopy:
Upper GI tract endoscopy is performed and is an ideal method for the diagnosis of peptic ulcers. In this, a small tube containing a camera is inserted from the mouth into the proximal small intestine. If the ulcer is present it usually appears like a severe aphthous ulcer with a creamy base.
It has also the ability to take biopsies if needed for further evaluation
Barium meal:
It is another method of diagnosis. In this person is given a thick liquid containing barium. After sometimes multiple X-rays are taken and a diagnosis is made by what picture is present in the X-rays.
Screening of the H pylori:
A screening test for H pylori infection should also be done as it is one of the major causes of peptic ulcers. Tests includes serological test to detect antibodies, urea breath test, and fecal antigen test. Invasive tests like biopsy urease test, bacterial culture, and histology is also done to detect the infection.
Gastric studies:
It includes measurement of basal secretion on response to injections of histamine, insulin, or pentagastrin. It is mainly indicated for the patient with hypersecretion continuing duodenal ulcer after gastric surgery.
Fasting plasma gastrin concentration:
In this injection of secretin is given. In a normal person, there is no change or little fall in plasma gastrin level. But it rises much in the case of ZE syndrome.
Complications
Bleeding:
It is one of the common complications of ulcers. If patients have black color stool or bloody or greyish coffee-colored vomiting, they should consult their doctor immediately.
Perforation:
It may be acute or chronic into the surrounding organs like the pancreas, liver, bile duct, or colon. In acute perforation, pain is continuous with muscle guarding or rigidity and tenderness on localized areas where the site of lesion is present. Malaise and fever may also some of the symptoms in perforation.
Pyloric stenosis or obstruction:
Nausea, anorexia, vomiting and loss of weight are common symptoms in this case.
Malignancy at site of ulcer:
Few cases of peptic ulcer may develop malignancy.
Treatment of peptic ulcer
Treatment is based on medical management or surgical intervention according to the conditions of the disease.
Indications for surgical treatment of peptic ulcer
- Perforation whether acute or chronic.
- Pyloric stenosis.
- Recurrent bleeding or severe hemorrhage or complication like anemia from bleeding.
- Evidence of adherent or penetrating ulcer.
- Intractability – recurrent or persistent distress despite most rigid medical management.
- Severe persistent hour-glass deformity.
- Very large ulcer.
- Combined gastric and duodenal ulcers.
- If malignancy suspected.
- Economic consideration.
- Repeated relapses of ulcers.
Indications for medical management:
- Short history of less than 5 years and a few relapses.
- Symptoms are very mild.
- Good social and economic position.
- There is no radiological evidence of penetrating ulcer, pyloric extraction, or marked duodenal deformity.
- The general condition of a patient is not suitable for surgery.
- Few chances of recovery after removal of organic lesion due to marked necrosis.
Medical management
Pharmacotherapy:
- H2 receptor antagonists like ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet), etc. used to reduce the production of gastric acid from parietal cells of the stomach by blocking histamine receptors.
- Proton Pump Inhibitors (PPIs) like omeprazole (Prilosec, Zegerid), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), esomeprazole (Nexium), etc. are used to reduce the production of stomach acid.
- Antacids like aluminum hydroxide, magnesium hydroxide, alginic acid (brand like Gaviscon) used to protect stomach mucosa from gastric acid.
- Mucoprotective drugs like prostaglandin analogs, misoprostol, sucralfate, mesopride, colloidal bismuth can also be used.
- Anticholinergic drugs like probanthine, pirenzepine can also be used. It is less used due to common side effects like dryness of mouth, blurring of vision, difficulty in urination.
- Eradication of H pylori: Various antibiotic combinations are used to eradicate the H pylori infection. We have discussed it in different article. Please read here for detail.
Rest:
Physical and mental rest is quite effective. Rest in bed during the acute phase and after subsidence of pain, rest for one week.
Anxiety and mental stress:
Relief from anxiety and mental tension is very important as ulcer symptoms get aggravated during a period of mental stress. Psychotherapy and antidepressants medicationare helpful. There are also some side effects of antidepressants medication. So it should be used with caution and under the observation of a psychiatrist doctor.
Diet:
Diet plays an important role in the healing of ulcers. Bland diet consisting of soft, very law spice and law in fiber food content is very helpful. Duration of a particular phase of the diet depends on the severity of the symptoms, response to any treatment, and cooperation and constitution of the patient. Food should be given at three hourly throughout the day, having small, digestible but adequate caloric value.
Avoidance of gastric irritants and stimulants:
Aggressive foods and habits that cause gastric irritation and stimulation like tobacco, alcohol, coffee, tea, sour fruits, ulcerogenic drugs, meat products, and extracts must be avoided for better results.
How to prevent the recurrence of the peptic ulcer?
Educating the patient:
- About the recurrent nature of the disease
- Avoid triggering factors like tobacco, coffee, tea, alcohol, hurried males, fried and spicy foods, excessive use of condiments and spices, meat extract, etc.
- No emotional stress
- Regular hours of rest and sleep and avoid excessive fatigue
- Avoid medicines that can reactivate ulcers like aspirin, NSAIDs, steroids, and rauwolfia.
Dietary management:
- Small food with regular intervals is helpful.
- Snacks between breakfast and lunch, and lunch and dinner, and a glass of milk before bedtime should be taken.
- Snacks may consist of biscuits, toast, chapatis with or without butter, light cake, sandwiches, curd, buttermilk, milk, custard, ice cream, etc.
Psychotherapy:
Helpful in patients with anxiety or depression or whenever indicated
Preparedness:
Intensified therapeutic regime on exposure to incidence which can aggravate ulcer such as acute respiratory infection, excessive work, or severe fatigue, insomnia, and nervous irritability due to emotional stress.